Depression: The Dark Side of Psoriasis

Don't Miss This

From insecurity and isolation to hopelessness and despair, life with psoriasis can be overwhelming. It's no wonder that depression and even thoughts of suicide are common.

In this HealthTalk webcast, psychiatrist Dr. Grant Halischuk provides insight into psoriasis and depression, and patient advocate Glennis Smitherman shares her experiences with leading a psoriasis support group. Find out how to tell if it's just "the blues" or if you're on the road to trouble. Learn about danger signs to look out for and hear expert strategies for getting the help you need

Announcer:
Welcome to this HealthTalk show. Before we begin, we remind you that the opinions expressed on this show are solely the views of our guests. They are not necessarily the views of HealthTalk or any outside organization. And, as always, please consult your own physician for the medical advice most appropriate for you. Now here's your host, Ross Reynolds.

Ross Reynolds:
Hello and welcome to this HealthTalk psoriasis webcast, Depression: the Dark Side of Psoriasis. I'm your host, Ross Reynolds. Joining us is Dr. Grant Halischuk. Dr. Halischuk is a psychiatrist in Menlo Park, California, with more than 20 years of experience. He has a particular interest in helping people cope with the emotional issues around medical conditions, including psoriasis. In addition to his private practice, he works at the Palo Alto Veteran's Administration healthcare system where he has helped develop mental healthcare delivery models. Dr. Halischuk received his medical training at McGill University in Montreal, Canada, and completed a psychiatric and residency fellowship in social and community psychiatry at Duke University. Welcome, Dr. Halischuk.

Dr. Grant Halischuk:
Thank you, Ross. It's a pleasure to be here.

Ross:
Also joining us this evening is Glennis Smitherman. Glennis is a psoriasis support group leader for the HOPE psoriasis support group in Cleveland, Ohio. HOPE stands for Hold On Pray Every day, which is her personal motto for living with psoriasis. She was diagnosed with psoriasis on her hands, feet and legs in 2003, and also has psoriatic arthritis. Glennis, thanks so much for being with us.

Dr. Halischuk:
Depression is a highly treatable mental illness which is typically of no single cause, although chronic medical illnesses like psoriasis can contribute significantly to its development. It is characterized most significantly by a sad or irritable mood state. It can range in severity from mild to severe, but it's qualitatively different from the Monday blues. It can cause enormous distress, and it has physical, psychological and behavioral components.

Also, unfortunately, it is relatively common in our society. Almost 10 percent of the U.S. population struggles with this illness, whether or not it's identified and they're getting treatment. Sadly, it is woefully undertreated or inadequately treated in this country as in many other countries. And psoriasis is another condition that fits those criteria of gross undertreatment. Looking at leading causes of disability worldwide, depression is right up there with cardiac disease.

Ross:
We all experience sadness or irritability. What are the signs that it's more than that, that it is depression?

Dr. Halischuk:
There are different signs that we in the mental health field would look at. A distinctly sad or irritable mood is a prominent sign, but we also look at multiple other factors including a markedly decreased level of interest or degree of enjoyment of activities that the individual was formerly quite interested in and enjoyed.

We also look at things like diminished sleep and decreased appetite; decrease in energy, memory and concentration; feelings of guilt and isolation; and increased anxiety. At its most extreme, there may be suicidal thoughts. Often, it presents with the individual maybe moving towards more drugs and alcohol than they might typically use to cope with this stress.

Ross:
Are there different types or severity of depression?

Dr. Halischuk:
Yes, there are many different types of depression. We might see some relatively mild depression that might need treatment, but depression we see as an illness, and it typically requires some degree of treatment. It might be relatively mild and go away after a number of months or weeks at times, but typically depression will last several months. Some depressions go on for years and are relatively unchanged, particularly with no treatment. So they can be quite debilitating in people's lives.

Ross:
If I'm depressed, do I have depression?

Dr. Halischuk:
That's a good question. That brings up an issue with the word "depression," which tends to be somewhat overused in our society. The way we in the mental health field use the word depression, we throw it around as a diagnosis. The way it's used in the general population typically is someone might say they're depressed, and we might not interpret that as the severity of a depressive illness that might require some treatment, either medication or psychotherapy, so, no, not necessarily.

Someone may say they're depressed about going back to work on Monday. And once they've been there a few hours, they may feel fine. That's not something that we would characterize as a depressive illness. That would be pretty normal.

Ross:You've worked a lot with people who have psoriasis. Do all of them have some degree of depression?

Dr. Halischuk:
As a clinical illness that merits treatment, no. But at the same time, I would say that depressive illness is fairly common in the population of individuals with psoriasis. There was a study in Italy recently that looked at patients with psoriasis, and a little over 60 percent of them suffered from some degree of depressive symptoms like those I outlined.

Ross:
I would assume that would track with the severity of the psoriasis – more severe psoriasis, more severe depression?

Dr. Halischuk:
It does not necessarily track that way. There have been a number of studies looking at various signs of anxiety, depression and other psychological symptoms in patients with chronic medical illnesses, including psoriasis. And it doesn't always correlate with the severity of psoriasis. That's one of the mysteries around it. You might find someone who has relatively mild psoriasis and fairly severe depression and another who has fairly extensive body involvement of psoriasis and relatively mild depression. So it's not always one-to-one.

Ross:
Is depression something you have to experience to begin to deal with, or are there ways that you can prevent depression from coming on?

Dr. Halischuk:
There are multiple things that we can all do to avoid depression coming on. My only hesitation in answering the question is that I don't want this to be seen as a fix-all, that if we follow these subsequent steps, we should never get depressed. And if we get depressed, we somehow failed in the prevention techniques. There are multiple causes of depression. One is chronic medical illness, and there are genetic factors involved. So for a subset of depressed individuals, nothing they do may totally relieve the depression without getting into some active treatment.

But things we can do to avoid them (the causes of depression) would be for starters, since we're talking in particular about psoriasis and depression, to acknowledge that you have the condition of psoriasis and find a good dermatologist and get into regular and effective treatment. Compliance with treatment is a real problem. There are studies that show that the worse the psoriasis, the worse the compliance with treatment, which is a sad correlation. But getting good treatment with psoriasis helps people with their symptoms and will decrease the likelihood of depression.

Staying active, being social, having family and friends around and letting them know that you have psoriasis and not feeling the need to hide it cuts down on some of the stigma. There are other things that people can do like look into the National Psoriasis Foundation, which has a wonderful Web site, www.psoriasis.org. These are some things that people can do.

Denying the illness tends to take people down the wrong road. And accepting it doesn't mean being passive about it but finding a way to actively live with it. Things like meditation and yoga have been shown to help reduce stress, and they can also be helpful in preventing depression.

Ross:
Also with us is Glennis Smitherman, a psoriasis support group leader in Cleveland, Ohio. Glennis, does this sound familiar to you? Have you experienced depression due to your psoriasis?

Glennis:
Yes, I have. Psoriasis is to me a very depressing disease. The disease is not something you want people to see. The way people have received me has not been very friendly. I'm a woman of color, and I have been discriminated against because of the color of my skin. But to be discriminated against because of the condition of my skin, that just set me right into depression. And, yes, I had to seek professional help to cope with that.

Ross:
Dr. Halischuk said that it can wreak havoc with relationships. It can mean that you lose enjoyment in activities that you used to enjoy doing.

What happened to you?

Glennis:
Swimming. I love to swim, but, of course, you have to get into a bathing suit, and the psoriasis is on my legs and hands, and the majority of it is on my feet. And you get stared at. And people are reluctant to get in the pool when they see that. So I had to stop going.

Ross:
What did you find was most helpful to you in battling depression?

Glennis:
Talking to my therapist helped a lot. He helped me see a lot of things that some people just don't understand.

I like to ride my bike and walk a lot, and I'm a choir member. So that helped me to cope with what I see and what I deal with every day.

Ross:
Are you okay with going back to the swimming pool?

Glennis:
Sooner or later, that's going to come, and I'm going to walk in there and say, "Look, this is not catchy (contagious). You have nothing to worry about. I want to enjoy a swim just like you."

Ross:
In your support , do you see a lot of people who are going through some kind of depression, and what are the kinds of stories that they have told you?

Glennis:
I've heard different stories. What I found was a month or a week later they actually laugh at the experience they've had. And I found that very enlightening. Instead of holding all this in, they're laughing at their experiences.

Ross:
Can you think of an incident where someone was very embarrassed or depressed about a situation, but a month later they could laugh at it?

Glennis:
I'll give you mine. I was in church, and there's a part of the service where we all hold hands and say the Lord's Prayer. When I held my hand out, the person next to me grabbed my hand. And when she looked at what was on it, she immediately took her hand down. That hurt, but I laughed at it later because by her actions she showed her face. You're supposed to have this faith (by being at church), but she showed how much faith she didn't have.

Ross:
How have you dealt with that? Have you had conversations with this person or other people in the choir who you will come into physical contact with?

Glennis:
Not too long ago, someone came to me and said, "What is that?" And I said, "Well, it's gotten worse." He said, "It has. It's spread up your arms." But he still hugged me and was okay with it. That person was very understanding.

Ross:
Had you already had the conversation with them about it not being contagious?

Glennis:
Yes, and I've never had any problems with this particular person.

Ross:Tell us more about some of the things that your support group can offer to psoriasis patients who are dealing with depression.

Glennis:
One thing that is very important is we connect with each other and share the experiences that we're having. When I was looking for a support group, there were none here in Cleveland. That's what inspired me to start one. Once we got started, I realized there were other people with similar experiences. That was very important in the support group. And we have outreach where we reach out to other communities and help other people.

Ross:
Dr. Halischuk, what are your thoughts about support groups?

Dr. Halischuk:
They're a great addition. And what Glennis is saying is very important. In general, they address the isolation and stigma around many kinds of conditions, and psoriasis is one of those conditions where there's a lot of isolation, and there's considerable stigma around it. So having a community of others who suffer from psoriasis and have gone through many similar emotions and experiences can be a great solace for people involved.

And it can also be quite educational for each person in the group to see how others cope or don't cope. Then it helps people to feel more strengthened to educate others and to be more comfortable with themselves.

Ross:
When you're working with people with psoriasis who may be experiencing depression, do you recommend that they go to a support group after you've finished working with them?

Dr. Halischuk:
No, I typically would encourage that as part of the process. Often, they may have already done that before coming to me and perhaps did not find that was quite enough to help them through what they were struggling with or wasn't quite adequate in some other way. But, regardless, if they have not been to one, I typically would recommend that.

One thing I would add is that I looked at a British study a few years ago that was examining the degree of disability in individuals with psoriasis, so looking at how it affected the broad gamut of activities in their lives. And they concluded something rather surprising, that psychological factors in these individuals were stronger determinants of degree of disability than the severity of the psoriasis.

So it's important for the dermatologists to look at what the emotional state is of the person, and for anybody with psoriasis to consider that (their emotions) and how that may be impacting on the disease process.

Ross:
Many people are going online these days for all sorts of things, including online support groups. Do people experience similar benefits if they're in a psoriasis support group online?

Dr. Halischuk:
They can. There are advantages and disadvantages. I think there's nothing like face-to-face contact and touch, and that can be important for individuals with a condition like psoriasis. On the other hand, given the stigma and isolation, I know of a number of folks who are regularly involved in support groups who don't show up, either because they're not comfortable being there in person, they can't afford to get there, or there's a geographic issue. So the Internet does open up these groups to larger populations of people, and people can benefit.

Ross:
If someone is worried about experiencing symptoms of depression, when is it time to go to a counselor or a therapist – how can they tell?

Dr. Halischuk:
There are a number of things that people can look at. One of the problems with a condition like depression is that given the lowered energy, the lowered motivation, and the helpless and hopeless feelings that are often typical in an individual with depression, unfortunately, all of those symptoms tend to argue against asking for help. So it becomes important that these folks have family and friends who are concerned. And when they don't, often the depression gets rather severe before anybody notices or they get in for help, and that's part of the problem.

But, in general, if somebody's feeling that their life is off, that they're just not feeling right and that they're feeling miserable all the time, that would be something. Often, people don't necessarily find that they're skipping work more, or younger folks skipping school more, but they find that it takes much more effort to do the things they used to do. Those are signs.

And if they get severe enough, people may start thinking, "It would be better off if I was dead. The world doesn't need me anyway. I look horrible with the psoriasis. Or I start perhaps dwelling on some minor skin lesion or scaling and start seeing that as so hideous that nobody else in the world should have to see it, and it may be better off if I was dead." It can get to that extreme, and that would be a red flag that you would need to get in right away and see someone.

Ross:
Glennis, has anyone in your support groups shown signs of serious depression?

Glennis:
If I detect that, I would just let that person know that sharing that experience with a therapist or a counselor would help them cope through that. But personally, I have not seen any real depression in our group.

Ross:
Are the folks in your support group also getting a lot of support at home?

Glennis:
Some are getting support at home – I am, from my children. In fact, my children come to the support group.

Ross:
And what does it give them to come to the support group?

Ross:
It gives them knowledge. My oldest son says, "My God, I've never seen anything like that in my life, and I want to know what's going on." And we've had a couple of doctors there, and he's very concerned about the medication. So, yes, my sons are there. They want to know what's going on with their mom.

Ross:
Did they ask to come, or did you ask them to come?

Glennis:
They came on their own.

Ross:Dr. Halischuk, what should a person look for in a therapist or a counselor, and how would they go about finding one?

Dr. Halischuk:
The most important thing to look for in a therapist or a counselor would be to find somebody that you can trust, that you feel comfortable talking with, because you're going to want to be with someone that you can share your innermost thoughts and feelings. And if you aren't doing that and you find you're hiding that, then you're defeating the purpose of being there.

I would recommend a licensed professional. And I suggest looking for a psychiatrist, a psychologist, a licensed clinical social worker, or a marriage and family counselor. There are a number of folks out there with licenses that would indicate some training in the mental health field, but they may also be a pastoral counselor.

If people aren't comfortable with that, I would suggest if you have a trusted family doctor that you start there. There may be a minister or priest in your life that you might feel comfortable talking with. You could go to your local university health clinic, and there are county mental health centers all over the country. Also, you could look at the National Psoriasis Foundation Web site, psoriasis.org. There are a lot of different ways people can go these days.

Ross:
When you have people in counseling do you include the family in that counseling?

Dr. Halischuk:
Yes. And sometimes the individual may not be comfortable with their family being included in their counseling, but I often will encourage that. And it will be up to them whether they will go for it. But that can be very important because that increases the circle of trust and support for that individual. I think it's important.

And, as Glennis mentioned, education is a huge part of all this. Not only does that potentially prevent worsening or development of depression in folks with chronic illnesses like psoriasis, but educating the family and friends cuts down on the likelihood of insensitive comments, and increases the likelihood of getting support from these folks, which everybody needs. We all need that.

Ross:
There's been a revolution in treating depression with the anti-depressant and anti-anxiety medications that are now available. When are those types of medications appropriate to take?

Dr. Halischuk:
There are a number of different ways to approach a clinical depression, one that's significantly interfering in someone's life that we would diagnose as such. One approach would be talk therapies. Another would be medication. Some people don't want to talk about the issues. They sometimes come in to someone in a position like mine and say, "Look, I want some medication to feel better. I don't want to talk about it too much." We may recommend that, but they may not want it. Other people come in, they don't want the medication, and they want to talk about it. Ideally, we have someone who is interested in at least considering both.

If somebody is showing significant impairment in relationships due to depression, anger, difficulty with motivation, and work is considering firing them those are clearly warning signs that treatment is not working. So if they're in therapy and these symptoms are developing or worsening, then that would be a sign to either intensify the therapy treatment or, if it's already fairly regular, I would suggest that medication would be something to consider. If they are not in any treatment at all, we would suggest medication right from the outset.

Ross:
Can medication for depression interfere with the medication some people take for psoriasis?

Dr. Halischuk:
There's not any absolute contraindication to taking antidepressant medication with the typical psoriasis treatments. We can look at the typical treatments for psoriasis just quickly. One would be topical ointments and creams. They're not a problem with any of the meds we would use. Another would be ultraviolet light treatment, and they're also not typically a major issue. Occasionally, the medicines may make one a little more sensitive to light, but it's not a huge problem.

Then the other one would be the newer biologic agents. They haven't been studied as far as I'm aware for drug interactions, but we haven't yet seen massive problems with them [combined with] antidepressant medications. So it's not really a reason to avoid them.

Ross:
Are there any medications that can help with depression and psoriasis?

Dr. Halischuk:
I see a few different ways to look at that. If you treat psoriasis alone with typical psoriasis treatments, treating the illness more successfully could decrease the likelihood of depression. The person will feel better, they have less skin symptoms, and they're out in the world more and get more support from others. They end up feeling better, and their depression may lift to some degree.

If you just treat the depression alone, treating depression typically decreases the feelings of stress people carry around inside them. We're all well aware that stress worsens psoriasis, and there's a lot of evidence to support that. So through treating depression alone, the psoriasis can improve. So those are the two ways of looking at it.

A third, and one of the more intriguing possibilities which I think requires more study, is there was research a couple of years ago on one of the newer biologic agents, Enbrel (etanercept). And it seems that this particular chemical acts on other chemicals in the body which are implicated in depression. One of the thoughts coming out of this study was that this medicine being used to treat psoriasis was also treating depression through a slightly different but associated mechanism. So there may be psoriasis treatments which in some ways are also antidepressant treatments. But that's a bit of a stretch. We can't prove that yet, but it's an interesting study. [Medical editor's note: Enbrel is a TNF inhibitor approved for use in psoriasis, as are Remicade (infliximab) and Humira (adalimumab). They all work by similar mechanisms.]

Ross:
Some folks might have a loved one with psoriasis, and they suspect that they have more than just a case of the blues, they may have depression. What would you suggest they do to help that family member?

Dr. Halischuk:
There are a couple of important things that a family member in that situation could do. One would be to offer significant emotional support. They need to be there for the person, take time with them, and acknowledge that they're not feeling good. Try to avoid statements like, "You really should just pull yourself up by your boot straps." I feel bad myself and I can snap out of it. That doesn't help somebody who's significantly depressed.

Depression is a distinct illness that you can't will yourself out of that easily. So being supportive [of the depressed person] but at the same time gently encouraging them out of the house, is one area where family and friends can be important. The other is to get them in for professional help. A person in that situation needs to get a proper diagnosis, and they need to get treatment. And there are other conditions that may mimic depression in an individual. As one example, somebody may have a hypoactive or low thyroid and that may look like depression in an individual, but they may need thyroid hormone, and it will clear up. So it would be important to get an accurate diagnosis and treatment. So that's the second thing family can help with.

Ross:
Glennis, when you were diagnosed with psoriasis and you began to experience some symptoms of depression was someone able to say something or do something to you that helped you? And what would you say to someone who might be worried about a friend or family member who has psoriasis and is acting like they're depressed? Glennis: Someone did tell me that they realized I was depressed, and they said to me, "You're not alone. You're not by yourself. There are others out there." And they encouraged me to realize I can help someone else and someone else can help me.

As far as encouraging a family member who is worried about a friend or a family member, I say, first of all, find out more about psoriasis. Know more about it. Be more aware of it. Then go to a support group yourself. The support groups are not just for the person with psoriasis, they're also for the family member or the friend.

Then maybe you can be more encouraging to that person. If you see that person laying around and feeling, "oh, woe is me," encourage them. Talk to them. If you see that something is little more serious, then maybe they need more professional help.

Ross:
Dr. Halischuk, you mentioned earlier that depression is highly treatable. How often is it able to be treated well?

Dr. Halischuk:
Most of the studies would support that two-thirds to three-quarters of people who come in for treatment can make some significant improvement. There are still a small percentage of folks that improve to a lesser degree, and there may be a lot of different reasons for that. But the majority of people who come in for treatment do improve significantly.

Ross:
You said earlier on that the severity of the depression does not necessarily track with the severity of psoriasis. Why would that not be?

Dr. Halischuk:
One reason would be that we need to see each person as an individual, and even someone who comes in with depression and psoriasis has a lot of other things going on in their life. They also may have a marriage that may be problematic, a boss who's driving them crazy, a child who's struggling in school, and a stubbed toe that's killing them the day they came in to see the doctor. There could be a lot of other things going on that can contribute to that picture.

Some folks are much more cup-half-full types versus cup-half-empty types, and someone with a more pessimistic outlook may in fact be more predisposed to developing depression in multiple different situations and may not respond as well to treatments, or may be more likely to see a relatively small psoriatic lesion as the end of the world versus someone else.

There's sometimes a difference between males and females on this, although you can't always make a facile assumption on that either. One might jump to the conclusion that women may be more sensitive to psoriasis than men, but I've seen men with psoriasis who are very sensitive to the most minor lesion and are very concerned about how other people may see it, or they see it as a personal weakness.

So everybody handles their condition differently. It's encouraging in some ways, because it's something that we can work with. And the fact that there are people with extensive skin involvement who still manage to go out every day with a smile on their face and have an active life is inspiring to people who can't and who may have less severe disease. And it hopefully gives them hope that they can get to that point themselves.

Ross:Let's go to our first question, which is from Portland, Oregon. "What do I do if a fellow member of my support group seems to be very depressed?" Dr. Halischuk?

Dr. Halischuk:
One thing to do is to talk with them a little about how they're feeling and try to get a sense of how they are and what they're looking for–whether they would like a friend or someone to talk with more in the group. I would suggest to ask them how down they are feeling and whether they are interested in talking with a professional about this. In which case, I'd suggest following some of the things I outlined earlier. See whether they have ever seen anybody in the [professional] field before, whether they know of a therapist around that they might feel comfortable talking to. Check in the yellow pages and look at the National Psoriasis Foundation website or a trusted family friend may have somebody to suggest.

Talking to a professional if they're struggling might be a good idea. Often friends will get in a little too deep. It's good to root around a little bit in how the person is feeling. But sometimes people get in a little over their head as far as providing support, and then they get to a point where the individual may be calling them at 10 at night and saying I'm not sure I can go on with this anymore. Then it becomes very stressful for everybody involved. And ideally we want to head those kinds of situations off at the pass.

Ross:
Glennis, what advice would you have for this person? Glennis: I would find out what they are feeling first and what the problem is. Then if I felt as though they were in a deep depression I would suggest they see a professional.

Ross:
Let's go to Oregon for an e-mail from Beaverton. "What should you do to help someone who has severe depression and will not seek help?" Dr. Halischuk?

Dr. Halischuk:
That's a tough one, and sadly that is a very common situation. Statistically, two-thirds of people in this country with some degree of depressive illness are not in treatment. And of the one-third who is in treatment, at least half of them, by the surveys that various mental health groups have done, are getting inadequate treatment. So the statistics are not great.

I think people who are uninterested in treatment really need support and understanding. So if you are a good friend of theirs, spend more time with them and explore their feelings a little more deeply. They may have all sorts of fears. So people may have considerable anxiety or fear around speaking with somebody in my field. So it may be that working through some of that with the person may help them. It may be that as a good friend or family member you could go in with them to that first appointment. Sit in the waiting room or maybe go right in the office with them.

It may help to talk with another friend or family member who perhaps has seen somebody in the mental health field before to take some of fear out of the whole equation. It may be that the person is assuming they're going to be put on medication and will be drugged up and won't be themselves any more. There are all sorts of anxieties and misconceptions people may have. A professional can do probably the best job of allaying those fears, but it may be that a friend or family member who's savvy about this can help the person through that process.

But it's important not to blame yourself if you can't get the person to go in. We all do the best we can, and some people just aren't ready for it.

Ross:
If a person is so depressed that they're suicidal, can some compulsory treatment be imposed on them?

Dr. Halischuk:
Yes. For starters, there are suicide hotlines around the country. And ideally the person who's struggling with this kind of condition will call a suicide hotline. They can talk to someone anonymously about how they're feeling and will get enough support and would certainly get some encouragement to go in. And the friend or family member could sit with them while they're making a call. That would be one option.

But, yes, there is what is known as commitment laws in each of the states. So if one had a family member who was thinking of killing themselves that person could call the police and they would come out and do what we call in California a welfare check. They [the police] have had some basic training in this area and would make a quick assessment on whether the person is at risk to themselves.

And they would bring the person in to a local health facility where they would get a psychiatric evaluation, and there would possibly be a decision made to hold that person potentially against their will for 24 to 72 hours, depending on what the law would cover in that state. During that time the person would be talked to and medication would be considered, and they possibly would come in to the mental health system that way and get some treatment.

Ross:
Helen from Cookeville, Tennessee, writes, "I've been told that I have arthritis connected with psoriasis. Since I lost my husband this past September I've noticed there seem to be more spots, split finger tips with bleeding, and the skin is peeling all over my fingers. I am taking something for depression, and the overwhelming feeling seems to not be as bad. But my question is do you think that the stress and depression has made treatments become ineffective in the control of arthritis and psoriasis? If that is so what would you suggest would help?"

Dr. Halischuk:
That certainly can happen. That's one of those examples where clearly stress and depression can worsen psoriasis, and, of course, a worsened psoriatic condition can make depression more severe. So it becomes a vicious circle.

There are different ways of approaching that. Ultimately she'll need to talk to her doctors about that. I assume she has seen somebody in both areas. But it takes time to work through losses, and it sounds like she probably has some issues that need to be worked on. And I anticipate that there will be further improvement in her psychological status over time. It hasn't been that long yet.

So I would hope over time that she would show further improvement. It might be that she needs some medication adjustment with the psychiatric meds. And it may also be that over time as treatments get better for psoriasis, she may need some tweaking with her dermatologic regimen. It may just take some time. Unfortunately, it's not a quick process, so it may take a number of months before that's manifested in her skin. It can be hard to precisely see a sudden change. It may take a while. She may not see the improvement for a while down the line.

Ross:Another person writes, "I have had psoriasis and depression for 13 years. Could the real cause of my psoriasis be depression?" Dr. Halischuk.

Dr. Halischuk:
We don't have any evidence that depression causes psoriasis. We have some evidence that depression worsens psoriasis signs and symptoms once it pops up in an individual, but we don't yet have evidence that it actually causes it. I would say no.

Ross:
This is from Beecher, Illinois. "There are times when I just don't like or want to be around other people. This often challenges my relationships at work. What can I do to suppress the way I feel and pretend everything and everyone is great?" Dr. Halischuk.

Dr. Halischuk:
That may be a sign of depression. We all have a different temperament. So the first question in assessing someone if they were in my office with a situation like this would be to try to get some sense of what their temperament is. Where are they on the sociability scale? Are they social individuals? Has this changed since they got the diagnosis of psoriasis and their skin became a problem? Has sociability been more of a problem since they became more depressed? If that is the issue then possibly they would need some treatment for that condition.

It might be someone like this would need more aggressive treatment, either on the psychological side or on the medical side to help with that. But I don't think there would be an easy way to change the attitude. One would have to specifically look at these relationships and what it is that is difficult. That would be one therapy approach.
Another would be to look at what we [mental health professionals] call cognitive behavioral therapy, which is very effective also. We look at the negative thoughts and behaviors that the person is having and try to reprogram those thoughts into a more positive frame of mind. That can make an enormous difference in our interactions on a day-to-day basis. And that can be very effective in a relatively short period of time, like a number of months.

Ross:
Can you suppress the way you feel, as this e-mail suggests this person would like to be able to do?

Dr. Halischuk:
Suppressing the way one feels is not entirely impossible with medication, but that would suggest blunting one's level of consciousness, which we physicians do not typically recommend. Although people do that all the time–they drink and take all sorts of substances of abuse. And they may very deliberately be doing that to suppress the way they feel, but it doesn't tend to be a healthy approach to life and doesn't fix anything. It's a short-term fix which usually creates other problems in their life.

Ross:
This is from Medford, Oregon: "It is hard to know when a person crosses the line, especially when dealing with an ongoing condition that never goes away. Is there treatment that will help for mild cases of depression so that it does not get extreme and suicidal?" Dr. Halischuk.

Dr. Halischuk:
A support group is one treatment that helps people with milder depressions. The person with the question is certainly right. It can be hard enough for people in the clinic or in the field to make assessments sometimes on individuals, so for the lay person without any particular training it can be pretty tough, much less for the person struggling with the problem.

If it seems relatively mild, support groups, talking to friends, educating themselves about the condition, and reading more about depression and psoriasis–all of those are very important.

There have been some very intriguing studies on mindfulness meditation, a particular type of meditation which is an offshoot of Buddhist meditative practices. In the study, they had two groups of patients with psoriasis who in ultraviolet light boxes. And one group was taught to do mindfulness meditation exercise while they were getting their ultraviolet light treatment, and the other group was the control group.

The ones who did the mindfulness meditation after X number of treatments had greater improvement in their skin lesions than the ones who were not engaging in the meditation. So the theory is that stress worsens psoriasis and decreasing stress improves psoriasis. And I would say decreasing stress also improves depression. So things like meditation, yoga, exercise, more education, sharing one's problems with friends, and avoiding alcohol and drugs are all good approaches for all of us in our lives, but in particular for someone who has mild depression.

Ross:
Glennis, have you seen your support group turn it around for people who came to the group acting and feeling depressed and later began to come out of it? Glennis: Yes. They'll come in and they're more or less watching and listening to everyone else. Then they'll start opening up and laughing and telling their own personal experiences. So, yes, I've seen that happen quite a bit.

Ross:
If someone comes to the support group are they going to get called on the first meeting? Are they going to be expected to step up and say something? Glennis: No.. The only thing I ask is that everybody introduces themselves. After that it's on you.

Ross:
Do you find some people who come to one or more meetings before they talk very much about their own issues? Glennis: No, it doesn't take long, because I have an exciting group.

Ross:
Dr. Halischuk, we got this e-mail from Mark. He wants to know if there are any medicines for treating psoriasis that can contribute to depression.

Dr. Halischuk:
Not that we know of, although there are side effects with the new biologic agents. That's probably the one class of treatment for psoriasis that would be most likely to create mood issues. At times people report milder depressions and anxiety symptoms with those agents, but there are bigger concerns with those agents typically along the medical lines than along the psychological lines. So at least as far as we know they're not usually a huge contributor to depression symptoms.

Ross:
Let's go to a caller we have in Anaheim, California. Caller: My question has to do with the potential that just having psoriasis–this autoimmune disease where the body is attacking itself–could that inner conflict physically give rise to a depressive psychology independent of one's involvement socially?

Ross:
So could it be that this battle going on inside the body is reflected somehow in one's psyche. What do you think about that, Dr. Halischuk?

Dr. Halischuk:
I wish I could answer it, but we don't have the data to answer that right now. As much as we do know right now, there's a lot of interest in brain processes, and there is immunologic research going on in multiple fields including the mental health field right now.

Ross:
We're just about out of time, and I want to go back to each of you to get any final advice you may have for listeners.

Glennis, any final advice you'd like to leave us with this evening? Glennis: By all means, contact the National Psoriasis Foundation, www.psoriasis.org. Talk about it to friends, family, or co-workers. The more you know about psoriasis, the better for the entire community. Get involved. Go to a support group. Support that person [who has psoriasis]. Help others.

Ross:
Dr. Halischuk, how about you, any final words?

Dr. Halischuk:
Having spent much of my career working with people with various stigmatizing mental illnesses, and, in fact, I have a mild psoriatic condition myself so I can relate to that personally as well as professionally, I would say that people with both conditions have a big burden. These are two conditions that are extremely difficult to live with, but they are both conditions where there are very good treatments. And there are a lot of people like Glennis and her support group, as well as professionals working with folks with these conditions, who can help. So I say, get some help. You deserve it, and you can get better.

Ross:
Dr. Grant Halischuk, a psychiatrist in Menlo Park, California, and also with us this hour, Glennis Smitherman, a psoriasis support group leader for a support group in Cleveland, Ohio, thanks to both of you for being so generous with your time.

Before we go, I want to remind you to visit the Psoriasis Community on HealthTalk.com, where you'll find blogs and lots of other information about psoriasis, including announcements about upcoming shows.

This site complies with the HONcode standard for trustworthy health information: verify here.

Advertising Notice

This Site and third parties who place advertisements on this Site may collect and use information about
your visits to this Site and other websites in order to provide advertisements about goods and services of
interest to you. If you would like to obtain more information about these advertising practices and to make
choices about online behavioral advertising, please click here.